Severe hemorrhage with necessity of allogeneic blood transfusion is common complication in intensive care unit and is associated with increased morbidity and mortality. Prompt recognition and treatment of bleeding causes becomes essential for the effective control of hemorrhage, rationalizing the use of allogeneic blood components, and in this way, preventing an occurrence of their potential adverse effects. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time present limitations in predicting bleeding and guiding transfusion therapy in critically ill patients. Viscoelastic tests such as thromboelastography and rotational thromboelastometry allow rapid detection of coagulopathy and goal-directed therapy with specific hemostatic drugs. The new era of thromboelastometry relies on its efficacy, practicality, reproducibility and cost-effectiveness to establish itself as the main diagnostic tool and transfusion guide in patients with severe active bleeding.

Background Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. Objectives We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. Patients/Methods Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. Interventions: Restrictive protocol, thromboelastometry‐guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (ie, fresh frozen plasma, platelets, or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion‐related adverse events. Results A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 ± 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry‐guided arm, and 14/19 (73.7%) in the coagulogram‐guided arm received blood transfusion (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01‐0.45; P = .002 for restrictive versus coagulogram‐guided arm; OR, 0.09; 95% CI, 0.01‐0.56; P = .006 for restrictive versus thromboelastometry‐guided arm; and OR, 0.77; 95% CI, 0.14‐4.15; P = .931 for thromboelastometry‐guided versus coagulogram‐guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion‐related adverse events was found. Conclusions The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.

BackgroundTransfusion therapy is associated with increased morbidity, mortality and costs. Conventional coagulation tests (CCT) are weak bleeding predictors, poorly reflecting coagulation in vivo. Thromboelastometry (ROTEM) provides early identification of coagulation disorders and can guide transfusion therapy by goals, reducing blood components transfusion.ObjectiveThe aim of this study is to describe coagulation profile of critically ill patients using ROTEM and evaluate the association between CCT and thromboelastometry.MethodsThis is a retrospective, observational study conducted in medical-surgical intensive care unit (ICU). Adult patients (≥18 years) admitted to ICU between November 2012 and December 2014, in whom ROTEM analyses were performed for bleeding management were included in this study. The first ROTEM and CCT after ICU admission were recorded simultaneously. Additionally, we collected data on blood components transfusion and hemostatic agents immediately after laboratory tests results.ResultsThe study included 531 patients. Most ROTEM tests showed normal coagulation profile [INTEM (54.8%), EXTEM (54.1%) and FIBTEM (53.3%)] with divergent results in relation to CCT: low platelet count (51.8% in INTEM and 55.9% in EXTEM); prolonged aPTT (69.9% in INTEM and 63.7% in EXTEM) and higher INR (23.8% in INTEM and 27.4% in EXTEM). However 16,7% of patients with normocoagulability in ROTEM received platelet concentrates and 10% fresh frozen plasma.ConclusionThe predominant ROTEM profile observed in this sample of critically ill patients was normal. In contrast, CCT suggested coagulopathy leading to a possibly unnecessary allogenic blood component transfusion. ROTEM test may avoid inappropriate allogeneic blood products transfusion in these patients.

IntroductionAcute fatty liver of pregnancy (AFLP) is a rare but life-threatening disease. AFLP is characterized by liver failure with different degrees of coagulopathy. Outcome and survival can be dramatically improved with prompt recognition and treatment. Thromboelastometry has been considered a point of care for the management of bleeding patients. It could, therefore, be an alternative tool to treat the complex cases of AFLP involving liver failure and coagulopathy. Through this study, we present our successful experience of an AFLP case that was submitted to an emergency cesarean section in which blood transfusion was guided by thromboelastometry.Case presentationWe report the case of a previously healthy 28-year-old woman, Afro-Brazilian, in her first pregnancy with no medical records until the 36th pregnancy week. She presented to our emergency department with an acute onset of abdominal pain, jaundice, nausea and vomiting. The laboratory examinations revealed metabolic acidosis, acute kidney injury (serum creatinine 3.4mg/dL), platelets 97 × 103/mm3, serum fibrinogen 98mg/dL and increased international nationalized ratio (INR 6.9) without acute bleeding. An emergency cesarean section was indicated. Based on the results of the thromboelastometric tests EXTEM and FIBTEM, prothrombin complex concentrate and fibrinogen concentrate were administered at the beginning of the cesarean section, which succeeded with no major bleeding and without need of further transfusion.ConclusionsThromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in obstetric patients with acute fatty liver of pregnancy, with the potential advantage of helping avoid unnecessary transfusion in such patients.

Key Clinical MessageApproximately 25–50% of septic patients develop disseminated intravascular coagulation. The thromboelastometry evaluates whole blood clot formation and dissolution in real time and has been considered for management of bleeding in diverse clinical conditions. We present a case of thromboelastometry‐guided bleeding management of a septic shock patient with overt disseminated intravascular coagulation (DIC).